Are we forgetting how to care?

The profound act at the heart of nursing.

Helen Cowan

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient

Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care. Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions?

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers.

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’.

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care.

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?”

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness.

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.”

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.

Essay

Culture

War & peace

23 February 2024

7 min read

Swords now, ploughshares later

There’s a moral case for investing in defence capabilities right now.

Tom Simpson

Tom Simpson is Associate Professor of Philosophy and Public Policy at the Blavatnik School of Government, University of Oxford.

A religious icon is propped on the side of a trench, a soldier can be seen further down the trench.

An icon of St Michael in a Ukrainian army trench.

It is two years since the Russian invasion of Ukraine, on 24 February 2022. We are still sleep-walking, with the British public and political class yet to grasp its implications. The risks of large-scale conflict have surged, and the British military is inadequately prepared for the operations it may soon be called on for. One day, swords will be turned into plowshares. But right now, in this imperfect world, we need more swords. Even if not widely enough, some have realised that the global order has changed. But fewer still are willing to act on that realisation.

The Russian assault in February 2022 was designed to shock. Repeating the plan which the Soviet Union had used in Afghanistan in December 1979, armoured columns advanced on the capital on multiple axes, preceded by an aviation assault into an airport just outside the main capital, intended to allow invading forces to ‘decapitate’ the government. The 2022 attack was also accompanied by strikes on key targets in Kyiv itself, with Russia mimicking the ‘shock and awe’ campaign with which coalition forces had initiated the invasion of Iraq in 2003.

The international situation has been parallel, with an immediate shock, galvanising intensive and often heroic action—but the resolve for which has withered with time. Some moments of demonstrated resolve among the public during the early months stand out in my memory. The students in Oxford who were fundraising not just for blankets for refugees, but for body armour, night-vision goggles and, if I remember rightly, even weapons. The stranger who bought a decrepit caravan from me for scrap saying, quietly and undemonstratively, that she would not buy fuel from Shell because it was blood oil. And, the 12-foot-tall statue in Oxford’s Broad Street of a Ukrainian soldier expressing the city’s solidarity.

This was echoed at the national level. In a welcome act of leadership, Boris Johnson, then Prime Minister, declared that Putin “must fail and must be seen to fail”. This gave the necessary direction for a series of forward-leaning policies, both economic and military, to support Ukraine.

The shock was short-lived, however, and in its place are concerning questions about both public and political resolve. The underlying issue is the significance of the Russian invasion of Ukraine. While the immediate consequences of this conflict are felt by Ukrainians, it matters more widely—to both the British and the global public. Realising these consequences, and then taking the appropriate action to address them, is now urgent. That action involves serious investment in defence industries, defence capability, and the military.

The lights on the dashboard of global security are all flashing—some amber, and some red.

The Russian invasion of Ukraine matters more widely in at least the following four ways.

First, it has incurred immediate costs on consumers globally. This sounds bland but is not. Soaring energy bills have cost lives, with the Economist estimating that the war indirectly killed more people in Europe in winter 2022 than Covid-19 did; so too do soaring food costs in countries which desperately need a steady, cheap supply of grain.

Second, the current course of the conflict in Ukraine has dramatically raised the risk of a confrontation between NATO and Russia, which may include either or both of conventional or hybrid conflict. Russia has not succeeded in turning Kyiv into a satellite state. But, unless NATO dramatically increases its supply of materiel, including high-end capabilities, the most likely outcome of the war is that Russia will successfully ‘freeze’ the conflict while controlling approximately a fifth of Ukraine, including the most economically productive part of the country in the East. Such success increases the likelihood of a revanchist Putin, seeking to establish Russian control over its claimed ‘historic’ borders and having put his economy on a war footing, attacking perhaps the Baltic states. Or Russia may simply seek to disrupt NATO countries in forms of conflict that fall short of conventional war, but risk escalation, as witness the recent Estonian arrests of ten people alleged to be part of a Russian destabilisation operation. The collective self-defence pact embodied in NATO’s Article 5 means that UK forces will be involved in any response to such aggression.

Third, the current inability for the US and Europe to act decisively, due to domestic political irresolution and polarisation, in the face of a clearly deteriorating security environment, emboldens potential adversaries. This is evident daily at the moment, with Republican politicians refusing to approve the $60 billion support package for Ukraine proposed by the Biden administration; as a result, the Ukrainian army has just withdrawn from Avdiivka, because it lacks the artillery shells to defend it. In a post-2016 timeline, and from an external perspective, the West now looks decadent.

Fourth, that Russia is likely to succeed in its war aims (unless something changes on the battlefield) further undermines the norms of non-aggression which are central to our currentrules-based international order. The domestic political trajectories of Russia, China, and Iran are not presently encouraging. All have stated goals which would see change in who controls relevant territories, and none rule out the use of force in achieving their goals.

The Russian invasion of Ukraine in February 2022, then, is an inflection point. The lights on the dashboard of global security are all flashing—some amber, and some red.

But Javelins do not descend ex nihilo from the clouds: they need to be manufactured by advanced industries.

In the face of such a deteriorating security environment, the urgent task for a responsible government is to ensure that it has the required military capability. This capability must be at minimum sufficient to defend its own citizens. It must also be sufficient to protect more widely those whom it has undertaken treaty commitments to defend. And, as a contribution to the wider public good, it is desirable that that capability should be sufficient to defend other innocent parties globally, subject to appropriate authorisation. Central to this capability is having a defence industry which will develop and manufacture the arms required.

The defence industry has frequently attracted criticism and controversy, with the most damaging charge being that it sells weapons to authoritarian regimes in corrupt deals. Exporting arms to regimes that will use them repressively, through corrupt contracts, is plainly wrong. But responding to this criticism does not require banning or otherwise abolishing the defence industry. Rather, the correct response is to reform it and then regulate it effectively, on the grounds that if war itself can sometimes be just, then the production of the tools required for war must itself be just.

If the state is, as St Paul had it, commissioned to punish the wrongdoer, ‘not bearing the sword in vain’, someone must make the swords.

The Russian invasion of Ukraine in 2022 was a paradigm of wrongful aggression; if war is ever justified as, I think, an imperfect world forces us to accept, it is in such circumstances. Those who would contest such aggression, in defence of innocent lives and sovereign states, need the weapons to be able to do so, and they need the best weapons that are available. One of the immediate actions that Ben Wallace, then UK Secretary of State for Defence, took in response to the invasion was to surge Britain’s stocks of man-portable anti-tank weapons to Ukraine. One of these, the Javelin weapon, literally gained iconic status, in the meme of ‘St Javelin’, styled as an Orthodox saint. But Javelins do not descend ex nihilo from the clouds: they need to be manufactured by advanced industries.

The defence industry, then, may certainly play a valuable role in a country’s economy. But more than that, in a world of predatory and repressive states, and violent non-state actors, it is a moral necessity. Isaiah foresaw, prophetically, a time when swords will be turned into ploughshares and spears into pruning hooks. But this side of that new reality, we need states that protect the innocent, and without a defence industry to equip the state to do so, the innocent lie vulnerable. If the state is, as St Paul had it, commissioned to punish the wrongdoer, ‘not bearing the sword in vain’, someone must make the swords. The peace dividend at the end of the US-Soviet Cold War has been spent, and we are in ‘the foothills’ of a new one, as the late Henry Kissinger described it. Ploughshares later; it must be swords now.

How long have we got? It is a basic principle of military planning that, while you should structure your own operations around the enemy’s most likely course of action, you should also, and crucially, have contingencies for the enemy’s worst-case course of action. That worst-case may be with us sooner that we think. In the lead-up to the recent Munich Security Conference, the Estonian intelligence chief estimated that Russia is preparing for confrontation with the West ‘within the next decade’; the chair of Germany’s Bundestag defence committee indicated five to eight years; and the Danish defence minister suggested three to five years.

With procurement timelines for advanced equipment—such as main battle tanks, frigates, and next generation fighter aircraft—typically taking over a decade, the urgent priority is for defence investment now. The UK’s Armed Forces are in a parlous state, as the recent cross-party report by the House of Commons Defence Committee makes clear. This investment in defence will not be cheap, and the difficult political task is deciding what spending to cut to allow for this uplift. But this debate cannot wait, and politicians must lead the country now in the required mind-set shift. Poland is the only NATO country to have convincingly demonstrated that it understands the times we live in, by investing seriously in its army. The UK government certainly wills the end, of ensuring the country’s security. The present question is whether it wills the means.

The St Javelin icon meme